Supportive Care (Part 1) Flashcards
Causes of constipation
- Disease-related
- Immobility
- IO
- low-residue diet, decreased food intake (not enough fibre) - Biochemical
- Hyperkalemia
- Hypercalcemia - Fluid depletion
- Reduced fluid intake
- Increased fluid loss
Complications of constipation include:
- Colic
- Confusion or restlessness
- Intestinal obstruction
What must you do before administering laxatives?
- check for intestinal obstruction
- consider underlying causes (hypercalcemia, drugs)
What are the different classes of constipation drugs?
- Bulk forming laxatives
- fybogel, metamucil - Stimulant laxatives
- Senna, bisacodyl - Osmotic laxatives
- Lactulose, PEG, phosphate enema, Forlax
Bulk forming laxatives:
- names of drugs
- MOA
- precautions/advice
- side effects
- fybogel, metamucil
- retain intraluminal fluid, softening faeces and stimulating peristalsis.
- patients must drink a lot of water, cannot take if they have intestinal obstruction
- colic, flatulence, unpalatable
Stimulant laxatives:
- names of drugs
- MOA
- precautions/advice
- side effects
- senna, bisacodyl
- directly irritate the smooth muscle of the small intestine, alter the water and electrolyte balance in the body such that there is a net retention.
- cannot take if your intestine is completely obstructed.
- side effects include: colic, flatulence, electrolyte imbalance.
Osmotic laxatives:
- names of drugs
- MOA
- precautions/advice
- side effects
- Lactulose, forlax, PEG, phosphate enema
- Draws fluid into the bowel via osmosis, to soften faeces and stimulate peristalsis.
- Patients must drink extra fluids.
- colic, flatulence, electrolyte imbalance, dehydration
rectum impaired, stool hard
- administer glycerin suppositories OR olive oil enema, followed by phosphate enema.
- Once disimpacted, administer oral stimulant or softener.
rectum impaired, stool soft
- administer bisacodyl or phosphate enema (rectal stimulant)
- once disimpacted, administer oral stimulant or softener.
rectum empty, not dilated
- exclude intestinal obstruction
2. administer laxatives as necessary, consider adding oral fleet (15mL for 3 days), as needed
rectum empty and ballooned
- give high fleet enema (phosphate enema) over several days until constipation resolves.
A. If colic is present then:
- reduce any stimulant and give an osmotic agent or softener (forlax/lactulose)
B. If colic is absent then:
- increase with stimulant laxative +/- softener
Advice on prevention of constipation
- Compliance in taking laxatives, as long as on opioids to prevent opioid-induced constipation.
- Encourage fluids generally, fruit juice and fruit specifically.
- Optimise patient’s existing laxative regimen
- Educate patient and caregiver on how to monitor bowel habits.
How is intestinal obstruction classified?
- Upper versus lower GI tract obstruction
- Mechanical versus functional
- Complete versus incomplete
Differences between upper and lower GI tract obstruction
- People with upper GI tract infection tend to vomit in large amounts, while those with small GI tract infection in small amounts.
- Abdominal distension is present in lower GI tract infection, but absent in upper GI tract infection.
- Constipation is an early feature of lower GI tract infection, but a late feature of upper GI tract infection.
- Anorexia is an early feature of upper GI tract infection, but a late feature of lower GI tract infection.
- Abdominal pain can be colicky, and is a common feature of both.
Approach to measurement for intestinal obstruction (potentially operable)
A. consider stenting if:
- Intestinal obstruction is an isolated case
- patients do not have rectal tumours
B. complete intestinal obstruction
- pain relief with opioids (morphine + anticholinergic agents like hyoscine, give buscopan if colic)
- for patients with nausea/vomiting: trial haloperidol, if not consider NGT or octreotide for high-dose vomiting.
- prokinetics may be contraindicated due to risk of perforation
Approach to measurement for intestinal obstruction (if not operable)
A. instead of stenting:
- consider steroids (8mg-16mg)
B. incomplete intestinal obstruction
- pain relief with fentanyl
- consider buscopan only if pain is not relieved
- treat nausea / vomiting with metoclopramide
- continue to clear bowels e.g. high fleet/lactulose
Intestinal obstruction dietary advice
- take a low residue/low fiber diet
- avoid any food made with seeds, nuts, raw or dried fruit
- avoid whole grain breads and cereals
- avoid raw fruits/vegetables. Remove skins before cooking.
- limit fat intake as this can increase stool bulk
- avoid tough, fibrous meats
Causes of diarrhoea
- Disease-related:
- pancreatic insufficiency, gastrointestinal infection, colitis, inflammatory bowel disease - Diet-related
- fruit, spices, alcohol - Treatment-related
- chemotherapy, radiotherapy
Before prescribing for established diarrhoea
Rule out faecal impaction, intestinal obstruction and infective causes
Types of medication for diarrhoea management
- Codeine phosphate
- Diphenoxylate/atropine (Lomotil)
- Loperamide HCI
- Octreotide
Codeine phosphate contraindications
- avoid concurrent use with other sedatives, narcotics or alchohol.
- not suitable for people with COPD, asthma, hepatic or renal disease.
Diphenoxylate/atropine (Lomotil) contraindications
- Age <12, liver disease, infectious diarrhoea
Loperamide HCI contraindications
- Age < 12, infectious diarrhoea
Octreotide contraindications
- infectious diarrhoea
Diarrhoea advice
- eat small, frequent meals
- eat low-fibre food (e.g. yoghurt, white rice, noodle, ripe banana, masked or baked potato without skin)
- maintain good fluid intake (2L/day)
- avoid high fibre food (e.g. whole grain breads, cereals, raw vegetables, beans, nuts, dried fruits))
- avoid coffee, tea, dairy products, alcohol and sweets
- avoid fried, greasy or highly spiced food
Causes of dyspnea
- Respiratory - pleural effusion, collapse/consolidation from tumour/pneumonia, PE, COPD
- Cardiovascular - pericardial effusion
- Abdominal - liver failure causing fluid overload, ascites causing diaphragmatic splinting
- Systemic causes, e.g. anaemia
Dyspnoea: management
- Steroids
- Anxiolytics
- Treatment of secretions
- Oxygen
- Opioids
Management of steroids
- thought to reduce peri-tumoural edema.
- administer dexamethasone
Management of anxiolytics
- useful for patients who are anxious and who are not responding to opioids alone.
- administer S/L lorazepam if patient is not able to take orally or is terminal
- IV midazolam for breakthroughs
If patient has longer prognosis and panic attacks, administer escitalopram
Management of treatment of secretions
- Administer 0.9% nebulised sodium chloride, provided patient can expectorate
- Anticholinergics (e.g. buscopan) can decrease and loosen secretions.
- Suctioning is not recommended as it is distressing and may not provide treatment relief
Management of oxygen
- trial for hypoxic patients (SpO2 < 90%)
Management of opioids
- Administer morphine
- Replace with fentanyl patches if patients have renal impairment
- Start opioids low, titrate carefully
Non-pharmacological advice for dyspnea
- Break tasks up into smaller bits. Plan and pace activities with aids when necessary.
- Learn breathing techniques
- Learn how to find comfortable positions (e.g. stacking pillows underneath their head/shoulders while lying down)
- open windows, get electric fans etc.
